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Chapter 30: Care Transition and Coordination Across the Community

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Chapter 30: Care Transition and Coordination Across the Community

10 problems · 0 figures

30-1 §30.RQ source ↗

Which transition of care intervention would the community health nurse perform when a client is discharged from the hospital to home?
  1. a.
    Assisting the client with activities of daily living
  2. b.
    Administering medications in the home setting
  3. c.
    Performing medication reconciliation
  4. d.
    Transporting client to medical appointments

Answer

C. Performing medication reconciliation
Transitional care refers to the provision of care to clients during transitions between different health care settings, ensuring continuity and safety. Medication reconciliation is an important intervention during transitional care to review and reconcile medication lists, address changes in medications, provide education, and promote adherence to prevent medication errors and adverse events during transitions.

30-2 §30.RQ source ↗

Which condition does the nurse recognize as increasing the risk of a poor outcome during a transition of care?
  1. a.
    A client being discharged from hospital to home
  2. b.
    A client with an identified social support system
  3. c.
    A client with limited health literacy
  4. d.
    A client with one provider

Answer

C. A client with limited health literacy
Limited health literacy increases the risk for a poor transition of care outcome. When clients struggle to understand health care instructions, medication regimens, or follow-up care, it can lead to misunderstandings, nonadherence, and suboptimal outcomes.

30-3 §30.RQ source ↗

The home care nurse is performing medication reconciliation with a client during the first home visit following hospital discharge. Which statement by the client requires follow-up by the nurse?
  1. a.
    “I understand why the doctor has stopped some of my medications.”
  2. b.
    “I have not seen that blue pill before.”
  3. c.
    “I set alarms on my phone to remind me to take my medications.”
  4. d.
    “I use a daily pill box to set up my medications.”

Answer

B. “I have not seen that blue pill before.”
Medication reconciliation is the process of comparing a client’s medication orders to all the medications the client has been taking and ensuring that the client has access to necessary medications during transitions to prevent medication errors. Since it also involves checking that the client has a clear understanding of their medication regimen, the nurse should follow up with this client to make sure that the “blue pill” is a current order and that the client understands what it is for and how to take it.

30-4 §30.RQ source ↗

The nurse, caring for a client who will be transferred from the hospital to a rehabilitation facility following a stroke, is using a care transition model to facilitate the transfer. Which explanation for the use of a care transition model will the nurse provide to the nursing student working the client?
  1. a.
    “Care transition models predict client outcomes during care transitions.”
  2. b.
    “Care transition models guide health care providers in the decision-making process.”
  3. c.
    “Care transition models support the coordination of care between health care settings.”
  4. d.
    “Care transition models focus on client education during care transitions.”

Answer

C. “Care transition models support the coordination of care between health care settings.”
Care transition models are designed to support seamless transitions between health care settings. They provide frameworks and guidelines to ensure coordinated and client-centered care during transitions, minimizing disruptions and improving outcomes.

30-5 §30.RQ source ↗

Which action will the nurse take when planning discharge for a client using the IDEAL Discharge Planning guide?
  1. a.
    Use accurate medical terms when educating the client and family about discharge instructions
  2. b.
    Engage clients and their families in the discharge planning process
  3. c.
    Ask the client if they have any questions to evaluate understanding of the discharge teaching
  4. d.
    Provide the client with a standardized discharge plan of care

Answer

B. Engage clients and their families in the discharge planning process
The IDEAL Discharge Planning guide engages clients and their families in the discharge planning process. Involving clients and their support systems ensures that the discharge plan aligns with their preferences, needs, and capabilities, ultimately improving client satisfaction and outcomes.

30-6 §30.RQ source ↗

Using the Transitional Care Model (TCM), which action would the nurse take when preparing an 81-year-old client with diabetes, hypertension, and heart failure for discharge home from the hospital following an exacerbation of heart failure?
  1. a.
    Provide the client with a standardized plan of care to follow
  2. b.
    Identify risk factors for readmission and develop an individualized discharge plan
  3. c.
    Refer the client to a discharge coach to encourage client self-management
  4. d.
    Contact the advanced practice nurse to coordinate the discharge from hospital to home

Answer

D. Contact the advanced practice nurse to coordinate the discharge from hospital to home
The TCM emphasizes the use of advanced practice nurses (APRNs) to coordinate care, educate clients and caregivers, and facilitate communication among various health care providers. It is designed to ensure the health and safety of high-risk older clients. TCM emphasizes client and caregiver education, promoting self-management and improving communication among health care providers.

30-7 §30.RQ source ↗

The community health nurse is facilitating transitional care for an older adult client between the hospital and home. Which action is a priority responsibility of the community health nurse in this transition of care?
  1. a.
    Providing direct client care in the home setting
  2. b.
    Educating clients about health promotion and prevention
  3. c.
    Coordinating care among health care providers
  4. d.
    Administering medication in the home

Answer

C. Coordinating care among health care providers
Community health nurses play a key role in coordinating care and advocating for clients across different health care settings. They ensure continuity of care, facilitate effective communication among health care providers, and support clients throughout their health care journey.

30-8 §30.RQ source ↗

A nurse is concerned about the increasing rate of hospital readmissions in clients due to not filling or picking up prescriptions at the pharmacy after discharge from the hospital. Which intervention should the nurse recommend to the hospital leadership to improve adherence to the medication regimen after discharge?
  1. a.
    Calling prescriptions in to the client’s pharmacy at discharge
  2. b.
    Handing client prescriptions for home medications during discharge instruction
  3. c.
    Providing client with home medications at discharge
  4. d.
    Telling the client that medication adherence will reduce readmissions to the hospital

Answer

C. Providing client with home medications at discharge
Research suggests that medication adherence is improved when clients are given their medications in the hospital at the time of discharge compared to needing to pick up prescriptions at a pharmacy.

30-9 §30.RQ source ↗

Which intervention by the community health nurse improves care for clients during the transition from behavioral health hospitalization to outpatient care?
  1. a.
    Ensuring effective communication among health care providers
  2. b.
    Reducing the number of providers involved in the client’s care
  3. c.
    Requiring medications to be taken under direct observation by a nurse
  4. d.
    Attending follow-up appointments with the client

Answer

A. Ensuring effective communication among health care providers
Ensuring effective communication among health care providers is a strategy to improve safety and continuity of care for clients during the transition from behavioral health hospitalization to outpatient care. This helps prevent miscommunication, enhances coordination, and ensures a smooth transition for clients.

30-10 §30.RQ source ↗

Which health information system would the nurse utilize to promote self-management in a client with diabetes who has been having difficulty controlling blood glucose levels?
  1. a.
    Decision support systems
  2. b.
    Mobile health applications
  3. c.
    Care coordination platforms
  4. d.
    Electronic health records

Answer

B. Mobile health applications
Mobile health applications can facilitate self-care by allowing clients to share data such as blood glucose levels with their health care providers to help manage their condition.

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Problems and answers are adapted from Population Health for Nurses by Jessica Ochs, Sherry L. Roper and Susan M. Schwartz, OpenStax, and are used under the CC BY-NC-SA 4.0 licence. Access for free at https://openstax.org/books/population-health/pages/1-introduction. Illustrations: Copyright Rice University, OpenStax, under CC BY-NC-SA 4.0 license. This adaptation is released under the same licence, is non-commercial, and is neither affiliated with nor endorsed by OpenStax or Rice University.